ELECTRONIC FUNDS TRANSFER (EFT) For Provider Payments

ELECTRONIC FUNDS TRANSFER (EFT) For Provider Payments Alameda Alliance for Health is pleased to announce the availability of Electronic Funds Transfer (EFT). Providers who enroll in EFT will have Fee-For-Service (FFS) payments deposited directly into their bank account. The EFT option is available to all contracted providers. To enroll in EFT, providers must complete the ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM that can be found at the end of this document. Prior to completing the form, please read the INSTRUCTION SHEET carefully and follow the directions. Providers with more than one National Provider ID (NPI) should attach a list of NPI numbers to the application. Please note that any attachments to the ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM must have an authorized original signature. Provider Groups that receive payments under the Group ID only need to complete one (1) single enrollment form for the Group NPI. Provider Group Members, who also bill individually, can enroll in EFT as an individual provider by submitting a separate enrollment form using their individual Provider NPI. Only one (1) TIN can be used per form. ONE (1) of the following items must be attached to your enrollment form: A voided check from your checking account. If you have a deposit-only checking account (and do not have checks) or you choose to have the EFT deposited into a savings account, you may submit a letter from a bank officer verifying your account information. The letter must be on bank letterhead and include the bank s name, address and routing number, the type of account, the account number, and the account owner s name, address and tax ID number. The letter also must be signed by a bank officer and notarized. EFT enrollment applications that do not meet these requirements will be rejected. After sending the ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM to Alameda Alliance for Health, please allow a minimum of four (4) weeks for processing. The EFT transactions will be transmitted to Alliance s bank on Thursday. Due to normal banking procedures, the transferred funds may not be available at your bank for up to three (3) business days after the transfer. Please contact your banking institution regarding the availability of your funds. If you have any questions about the EFT process, please call Alameda Alliance for Health Provider Relations at 510-747-4510 If you would like to Electronic Remittance Advice (ERA) and haven t enrolled please follow this link and enroll today: EDI Trading Partner Agreement Form. Page 1.v9

INSTRUCTIONS FOR ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM Providers wishing to request EFT of Alameda Alliance for Health FFS funds must complete and return an ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM, along with a blank check from the checking account to which the funds are to be transferred. The check must contain the name and address of the provider or provider organization and the word VOID must be written across its face. OR If you have a deposit-only checking account (and you do not have checks) or you choose to have the EFT deposited into a savings account, you may submit a letter from a bank officer. The letter must be on bank letterhead and include the bank s Name, address and routing number, the type of account, the account number, and the account owner s name, address and tax ID number. The letter also must be signed by a bank officer and notarized. Sections A and B of the EFT form must be complete and legible, otherwise, the request will not be processed and will be returned. Section A: Provider Information Step 1 Enter the Provider s Name: Complete legal name of the institution, corporate entity, practice, or individual provider as it is filed with Alameda Alliance for Health. Step 2 Enter the Provider Identifier National Provider ID (NPI) (or Group NPI if payment is made to a Group Practice). Providers with more than one NPI, attach a list of NPI numbers to the application. Provider Groups that receive payments under the Group number need only to complete a single enrollment form for the Group NPI. Provider Group Members, who also bill individually, can enroll in EFT as an individual provider by submitting a separate enrollment form using their individual Provider NPI. Step 3 Enter the Doing Business As (DBA) name: A fictitious business name, under which the business or operation is conducted and presented to the world and is not the legal name of the legal person (or persons) who actually own it and are responsible for it. Step 4 Enter the Provider Identifier Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN). Step 5 Enter the Provider Contact Name: Name of contact in provider office for handling EFT issues. Step 6 Enter Telephone: Associated with contact person. Step 7 Enter Email Address: An electronic mail address in which the health plan might contact the provider. Step 8 Enter Provider Address: The number and street name where a person or organization can be found, City, State and Zip Code. Page 2.v9

Step 9 Enter Provider Agent Name: Name of provider s authorized agent. Step 10 Enter Provider Agent s Telephone Number Step 11 Enter the Provider Agent s Address. Step 12 Enter Provider Agent Email Address. Section B: Banking Information Step 1 Enter the Financial Institution Routing Number: A 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited. Numbers can be found at the bottom of your check. Step 2 Enter the Provider s Account Number with Financial Intuition: Provider s account number at the financial institution to which EFT payments are to be deposited. Step 3 Type of Account at Financial Institution: The type of account the provider will use to receive EFT payments, e.g. Checking, Saving. Step 4 Financial Institution Name: Official name of the Provider s financial institution. Step 5 Financial Institution Address: Street Address associated with receiving depository financial institution name field, City, State, Zip Code. Section C: EFT Authorization or Cancellation Providers should complete and sign this section. All documents received will be processed and placed in the provider s file. Please note: For providers who have claims paid within a particular payment cycle, FFS funds are normally scheduled to be transferred on Thursdays. Due to normal banking procedures, the funds may not become available in the provider s account for up to forty-eight (48) hours from the initial transmission. Please contact your banking institution with questions about the availability of funds. Please allow a minimum of four (4) weeks for your ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM request to be processed. To change banking information, providers must send the following: A new ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM indicating the new banking information. The enrollment form must be signed with an original signature and a title must be indicated. A voided check with the new account and routing numbers must be attached to the new enrollment form. If the account is a deposit only account, attach a signed, notarized letter from your banking institution indicating the new account and routing numbers. Regardless of what is being updated, both the account and routing numbers must always be indicated. A letter indicating changes to your account is required. The letter must be on company letterhead and include any provider number(s) (tax ID and NPI), new account and routing numbers and a brief explanation for the change. The letter must have an original signature and a title should be indicated. Note: If you are changing your EFT from one banking institution to another banking institution, your payments will automatically transfer back to paper for a minimum of two (2) weeks while your EFT is being set up on your new account. Page 3.v9

To cancel EFT transactions, providers must send an ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM, including the provider number(s), applicable Tax ID and/or NPIs, to the address below. Please allow a minimum of four (4) weeks to transition to a paper check. Email, Fax or Mail the completed form with the voided check and attachments (if applicable) to: OR Email: Finance@alamedaalliance.org ATTN: Alameda Alliance (DBA/Provider Name) Mail: Alameda Alliance for Health, Attention: EFT Processing - Finance Dept. 1240 South Loop Road, Alameda, California 94502 OR Finance Dept. Fax: 510-995-3709 Questions about completing the form should be directed to Alameda Alliance Provider Relations Department at 510-747-4510. Page 4.v9

ELECTRONIC FUNDS TRANSFER AUTHORIZATION Alameda Alliance for Health: This authorization remains in full force and effect until Alameda Alliance for Health receives written notification from the provider of its termination, or until Alameda Alliance for Health or an appointing authority deems it necessary to terminate the agreement. SECTION A: PLEASE PRINT OR TYPE 1. NAME OF PROVIDER (must match name on bank account and name registered with AAH) 2. PROVIDER IDENTIFIER NPI NUMBER ( attach the Providers with more than one NPI form below if multiple NPI s) 3. DOING BUSINESS AS NAME (DBA) 4. PROVIDER IDENTIFIER (TIN OR EIN, only one TIN/EIN per form) 5. PROVIDER CONTACT NAME 6. TELEPHONE PHONE NUMBER (REQUIRED) 7. EMAIL ADDRESS 8. PROVIDER ADDRESS City State Zip Code 9. PROVIDER AGENT NAME (Name of provider s authorized agent) 10. PROVIDER AGENT TELEPHONE NUMBER (REQUIRED) 11. PROVIDER AGENT ADDRESS City State Zip Code 12. PROVIDER AGENT EMAIL ADDRESS SECTION B 1. FINANCIAL INSTITUTION ROUTING NUMBER 2. PROVIDER S ACCOUNT NUMBER (include leading zeros) 3. TYPE OF ACCOUNT AT FINANCIAL INSTITUTION CHECKING SAVINGS 4. FINANCIAL INSTITUTION NAME 5. FINANCIAL INSTITUTION ADDRESS City State Zip Code Page 5

SECTION C (Check the appropriate box) I hereby authorize Alameda Alliance to initiate credit entries to my bank account as indicated above, and the depository named above to credit the same to such account. For changes to existing accounts, do not close an existing account until the first payment has been deposited into the new account. I hereby CANCEL my EFT authorization I understand that by signing this form, payments issued will be from Federal and State funds, and that any falsification or concealment of a material fact may be prosecuted under Federal and State laws. Authorized Signature: Date: Title: Print Name: (PRINT the form, sign; (signature must be owner, partner or corporate officer), and send it via mail, fax or email.) Mail This Completed Form To: Email/Fax Only: Alameda Alliance for Health ATTN: Alameda Alliance for Health [DBA/PROVIDER NAME] ATTN: EFT Processing Finance Dept. Finance@alamedaalliance.org / Fax: 510-995-3709 1240 South Loop Road Alameda, California 94502 Privacy Statement (Civil Code Section 1798 et seq.): The information requested on this form is required by Alameda Alliance for Health for purposes of identification and document processing. Furnishing the information requested on this form is mandatory. Failure to provide the mandatory information may result in your request being delayed or not processed. Internal Use Only: Reviewed by: Finance signatory: Date signed: SR Number: Page 6

Providers with more than one NPI Providers with more than one NPI, attach a list of NPI numbers to the application. Provider Groups that receive payments under the Group number need only to complete a single enrollment form for the Group NPI. However, members of Provider Groups who also bill individually may enroll by submitting a separate enrollment form using their individual provider number. Provider Group/Individual Name Provider Group/Individual NPI AAH Use Only Authorized Signature: Date: Title: Print Name: (PRINT the form, sign; (signature must be owner, partner or corporate officer), and send it via mail, fax or email.) Page 7